Excellus BCBS

  • Magnetic Resonance Imaging (MRI) of the Breast (Breast MRI, CAD MRI) (PDF) Policy 6.01.35 (posted 7/7/14)
  • CT (Computed Tomography) Perfusion Imaging - Dynamic Perfusion CT, Multimodal CT, Perfusion CT, Xenon-enhanced CT (XeCT) (PDF) Policy 6.01.37 (posted 6/16/14)
  • Coronary Calcium Scoring : Electron Beam CT (EBCT), Helical CT, Spiral CT, Multidetector Row CT (MDCT), Ultrafast CT, Cardiac Calcium Scoring (PDF) Policy 6.01.13 (posted 1/29/14)
  • Cardiac Computed Tomographic Angiography (Calcium Scoring, Cardiac CTA, Coronary Artery CTA, CT Angiography) (PDF) Policy 6.01.34 (posted 7/23/14)
  • Breast Biopsy, Percutaneous (ABBI, Mammotome, SiteSelect) (PDF) Policy 6.01.04 (posted 10/24/13)
  • Bone Densitometry/Bone Density Studies: DEXA Scan, Dual Photon Absorptiometry (DPA), Morphometric X-ray Absorptiometry, Single Photon Absorbtiometry (SPA), Ultrasound Measurement of the Heel (PDF) Policy 6.01.05 (posted 10/2/14)
  • Stereotactic Radiosurgery and Stereotactic Radiotherapy (e.g., CyberKnife, Gamma Knife Radiosurgery, Linear Accelerator, Linac) (PDF) Policy 6.01.12 (posted 8/25/14)
  • Selective Internal Radiation Therapy (SIRT) for Hepatic Tumors (SIR-Spheres, Theraspheres) (PDF) Policy 7.01.69 (posted 7/7/14)
  • Proton Beam Radiation (Charged Particle, Conformal) (PDF) Policy 6.01.11 (posted 8/25/14)
  • Peptide Receptor Radionuclide Therapy (PRRT, PRRNT): Receptor-Mediated Radiotherapy, Radiolabeled Nuclide Therapy, Somatostatin Analog, 90Y-DOTATOC, 177Lu-DOTA0, Tyr3, 90Y-DOTA0 (PDF) Policy 7.01.78 (posted 3/4/14)
  • Intravascular Brachytherapy, Endovascular Radiation (PDF) Policy 6.01.15 (posted 8/4/14)
  • Intensity Modulated Radiation Therapy (IMRT) (PDF) Policy 6.01.24 (posted 8/25/14)
  • Brachytherapy or Radioactive Seed Implantation for Prostate Cancer (PDF) Policy 6.01.16 (posted 7/7/14)
  • Brachytherapy after Breast Conserving Surgery, as Boost with Whole Breast Irradiation or Alone as Accelerated Partial Breast Irradiation: Accelerated Partial Breast Irradiation, APBI, Axxent, MammoSite (PDF) Policy 6.01.30 (posted 8/25/14)
  • Vagus Nerve Stimulation (PDF) Policy 7.01.05 (posted 10/2/14)
  • Topographic Brain Mapping (TBM), Brain Activity Mapping (PDF) Policy 2.01.22 (posted 12/9/13)
  • Spinal Injections (Epidural and Facet Injections) for Pain Management : Medial Branch Block (PDF) Policy 7.01.87 (posted 8/4/14)
  • Spinal Cord/Dorsal Column Stimulation (PDF) Policy 7.01.51 (posted 7/7/14)
  • Selective Posterior (or Dorsal) Rhizotomy for Cerebral Palsy (PDF) Policy 7.01.20 (posted 1/14/14)
  • Quantitative Sensory Testing (QST) (PDF) Policy 2.01.34 (posted 10/2/14)
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